I. Introduction
I personally selected this case of Acute Myelogenous Leukemia (AML) to
enhance my knowledge concerning its clinical manifestations, possible causes,
cure and prevention, among others. This knowledge will eventually become an
indispensable tool that can be shared to others and will never go out of style. It is
a privilege to embrace this challenge in the form of service to humanity and the
fulfillment of our nursing profession. Our core competence is the bare essential
towards its success.
As a nursing profession, it is imperative to learn new techniques in
modern science in order to develop skills that would benefit the medical world.
This learning potential must be relayed to posterity and develop new techniques,
state -of –the- art technology that caters the modern man. In the final analysis, the
achievement of one’s endeavor may usher us to find the light we are seeking for.
First of all what is leukemia? Leukemia is a cancer of the blood, and is
characterized by uncontrolled proliferation and accumulation of leukocytes (white
blood cells). Most leukemic cells never mature into functioning leukocytes.
Where in the body is deprived of vital components of its immune system. Also,
the cells accumulate in the blood and in certain organs, forcing out healthy cells
and interfering with the function of that organ. There many different types of
leukemia but the four most important forms are derived from only two types of
cells, lymphocytes and myelocytes. Acute myelogenous leukemia is disorders of
granulocytes. Granulocytes produced by bone marrow, engulf and digest bacteria
and other small particles. This generally appears suddenly with symptoms like
those of cold, and progresses rapidly. The lymph nodes, spleen and liver may
become infiltrated with leukocytes and enlarged. There is often bone pain,
paleness due to anemia, a tendency to bleed easily because of depleted platelets
and high susceptibility to infections. The most common causes of death, which
occurs on the average within three months if without treatment, are hemorrhaging
and uncontrolled infections. Acute myelogenous leukemia occurs much less
frequently in children.
II. Objectives
General Objectives:
After 3 days of giving holistic care, the patient will be able to regain optimum
level of functioning and adopt coping skills in performing activities of daily living.
Specific Objectives:
After 8 hours of giving holistic nursing care, the patient will be able to:
1. establish rapport with the student nurse
2. explain reasons of hospitalization
3. state past medical history related to present condition
4. identify the precipitating and predisposing factors that can possibly lead to the occurrence
of the condition
5. discuss the management applied upon the occurrence of the disease
After 8 hours of giving holistic care, the student nurse will be able to:
1. establish rapport with the patient
2. present the patient’s personal history
3. assess the patient’s level of growth and development
4. show present profile of functional health patterns
5. discuss with the patient the different predisposing and precipitating factors
6. identify the pathophysiology and rationale
7. construct a comprehensive nursing care plan appropriate for the patient
8. discuss different measures for home management
PHYSICAL ASSESSMENT
Body Parts Inspection Palpation Percussion Auscultation
HEAD
HAIR
SCALP
FACE
FOREHEAD
EYEBROWS
EYELIDS
EYELASHES
CONJUNCTIVA
SCLERA
PUPIL
Round in shapeNormocepahlic
Evenly distributed, Black in color, short, straight hair, smooth
No dandruff
Presence of pimples noted, No wrinkles, brown in color
Round, brown in color, No wrinkles, pimples noted
Black in color, no lesions noted
Closes and opens without difficulty
Equally distributed
Pale, moist
Opaque in color, moist
Pupil equally round reactive to light and accommodation, Constricts and
No tendernessNo Lumps
No Lumps noted
No Lumps noted
No Lumps noted
No Mass noted
IRIS
LACRIMAL
EXTRAOCULAR EYE MOVEMENT
LIPS
MOUTH
TONGUE
TEETH
PALATE
UVULA
TONSILS
NOSE
dilates
Dark brown in color
Pale, no discharges
Moves without any difficulty, follows the six cardinal gaze
Pale in color, symmetrical
Gums are pale, fair in size, dry
Pinkish in color, whitish palate present
Yellowish with a complete set of teeth
Hard and soft palate are pale in color
Rises upon saying “ah”, medially located
Pale in color
Has discharges, nasal mucus noted, centrally located, not patent, septum located medially, no lesions, nasal flaring was not noted
No mass noted
No mass noted
EARS
NECK
SKIN
EXTREMITIES: UPPER:
CHEST
HEART
LUNGS
ABDOMEN
Symmetrical, ear wax noted, can hear clearly, auricle aligned with outer canthus
Brown in color, symmetrical, can perform ROM exercises, lymph nodes are not inflamed
Brown in color, petechiae was noted in both lower and upper extremities (pin point like appearance), Temperature of 36.8 degree Celsius
Without IV, can perform limited ROM exercises, petechiae was noted (pin point like appearance)
Equal chest expansionRR: 24 breaths per minute
Brown in color, no abdominal
Carotid pulse: 78 beats per minute, no lumps noted
Vibration felt upon tactile fermitus
BP: 100/60 mmhg
Clear breath sounds
Bowel sounds: 3 upon
LOWER:
distention
Can perform limited ROM exercises, presence of petechiae (pinpoint like appearance) on his both legs
auscultation
III. Nursing Assessment
1. Personal History
1.1 Patients Profile
Name: Mr. Abella, Fernando
Age: 50 years old
Sex: Male
Civil Status: Married
Religion: Roman Catholic
Date of Admission: February 04, 2007
Room No. : 532
Complaints: tonsillitis
Diagnosis: Acute Myelogenous Leukemia
Physician: Dr. Ponce, Susie
1.2Family and individual information, social and health history
Mr. Abella, Fernando, 50 yrs. Old, male, Filipino Roman Catholic, who is married and has four
children, all of which are still schooling. The patient works in a government office. The patient is always
exposed in petroleum products and paints. Mr. Abella is not hypertensive, diabetic and asthmatic. He is
an occasional drinker and a positive smoker which he consumes one pack per day. Mr. Abella was
rushed in the emergency room of Cebu Doctor’s University Hospital because he fainted and was very
pale. He also complains of tonsillitis.
1.3. Level of growth and Development
Normal Development at Particular Stage
The patient belongs to the middle adulthood. The middle years, from 40 – 65, have been
called the years of stability and consolidation. For most people, it is a time when children have grown
and moved away or are moving away from home. Thus, partners generally have more time for and with
each other and time to pursue interests they may have deferred for years.
The middle adulthood, the individual makes lasting contributions through involvement
with others. During this period, personal and career achievements have often already been experienced.
Many middle adults find particular joy in assisting their children and other young people to become
productive and responsible adults. They may also begin to help aging parents. Using leisure time in
satisfying and creative ways is a challenge that, if met satisfactory, enables middle adults to prepare for
retirement.
Men and women must adjust to inevitable biological changes. As in adolescence, middle
adults use considerable energy to adapt self concept and body image to physiological realities and
changes in physical appearance. High self-esteem, a favorable body image, and a positive attitude
toward physiological changes are fostered when adults engage in physical exercise, balanced diet,
adequate sleep, and good hygiene practices that promote vigorous, healthy bodies.
Physical Changes
A number of changes take place during the middle years. At 40, most adults can function
as they did in their twenties. However during ages 40 – 65, many physical changes takes place. Both men
and women experience decreasing hormonal production during the middle years. The menopause refers
to the so called change of life in women, when menstruation ceases. It is said to have occurred when a
woman has not had a menstrual period within a year. The menopause usually occurs anywhere between
ages 40 – 55. The average is about 47 years. At this time, the ovaries decrease in activity until ovulation
ceases. Psychologically, the menopause can be anxiety- producing time, especially if the ability to bear
children is an integral part of woman’s self concept. The hair begins to thin and gray hair appears. Skin
turgor and moisture decrease, subcutaneous fat decreases and wrinkling occur. Fatty tissue is
redistributed, resulting in fat deposits in the abdominal area. Skeletal muscle bulk decreases at about
age 60. Thinning of the intervertebral disk causes a decrease in height of about 1 inch. Calcium loss from
bone tissue is more common among postmenopausal women. Muscle growth continues in proportion to
use. Blood vessels lose elasticity and become thicker. Visual acuity declines, often by the late forties,
especially for near vision (presbyopia). Auditory acuity for high- frequency sounds (presbycusis) also
decreases, particularly in men. Taste sensations also diminish. Metabolism slows, resulting in weight
gain. Gradual decrease in tone of large intestine may predispose the individual to constipation. Nephron
units are lost during this time, and glomerular filtration rate decreases. Hormonal changes take place in
both men and women.
Cognitive Changes
The middle- aged adults’ cognitive and intellectual abilities change very little. Cognitive
processes include the action time, memory, perception, learning, problem solving, and creativity.
Reaction time during the middle years stays much the same or diminishes during the later part of the
middle years. Memory and problem solving are maintained through middle adulthood. Learning
continuous and cab be enhanced by increased motivation at this time in life.
Middle-aged adults are able to carry out all the strategies described in Piaget’s phase of
formal operations. The experiences of the professional, social, and personal life of middle-aged persons
will be reflected in their cognitive performance. Thus, approaches to problem solving and task
completion will vary considerably in middle-aged group. The middle-aged adult can “reflect on the past
and current experience and can imagine, anticipate, plan and hope”.
Changes in the cognitive function of middle adults are rare except with illness are
trauma. The middle adult can learn new skills and information. Some middle adults enter educational or
vocational programs to prepare themselves for entering the job market or changing jobs.
Moral Changes
During this stage, rules and laws are valued because they maintain social order worth
preserving. Morality is guided by higher principles of human conduct. Individuals appreciate the social
purposes served by laws. They believe laws should be derived from a democratic consensus. Individuals
search their own conscience for universal ethical principles. They do not make up their own rules but
instead arrive at abstract principles that all religions or moral authorities might view as compelling or
fair. There is a correlation between higher stages of reasoning and higher levels of moral behavior.
According to Kohlberg, the adult can move beyond the conventional level to the post
conventional level. Kohlberg believes that extensive experience of personal moral choice and
responsibility is required before people can reach the post conventional level. Kohlberg found that few
of his subjects achieved the highest level of moral reasoning.
Psychosocial Development
The psychosocial changes in the middle adult may involve expected events, such as
marital separation. This change may result in stress that can affect the middle adults’ over all level of
health. In the middle adult years, as children depart from the household, the family enters the post
parental family stage. Time and financial demands on the parents decrease, and the couple faces the
task of redefining their own relationship. According to Eriksons’ developmental theory, the primary
developmental task of the middle years is to achieve generativity. Generativity is the willingness to care
for and guide others. If middle adults fail to achieve generativity, Stagnation occurs. This is shown by
excessive concern with themselves or destructive behavior toward their children and community.
Spiritual Changes
As man grows older he becomes more aware of the outside world. Some conform when they
are forced to do so, some are driven by self interests and will do only what they must do to get what
they want in return. They violate God’s law regularly, sinning more or less everyday with little remorse.
Their spiritual senses are not alert. They are ignorant of God and have no concept of holiness. But as
man grows older, he becomes more conscious of how important people really are. “Being good” is now
important. He thinks about how other people see him and how they must feel. He realizes that the
world runs according to rules. The desire to please other drives him and when he fails his first response
is to justify himself. This faith is based on the beliefs of the community.
In adult life many individuals develop a faith that is purely their own individual faith and
can deal with the paradoxes and ironies of human existence. A final stage of development finds some
individuals making a commitment to universal values, such as love and justice. The focus on the value of
experience and reflection and intellectual development finds a strong parallel in the importance given to
the rule of experience and reflection in spiritual growth.
Sexuality Changes
After the departure of their last child from the home, many couples recultivate their
relationships and find increased marital and sexual satisfaction during middle age. The onset of
menopause and the climacteric can affect the sexual satisfaction during the middle adult. Other factors
influencing sexuality during this period include work stress, diminished health of one or both partners,
and the use of prescription medications.
Diagnostic Test Normal Value Result Significance
Hemoglobin
Hematocrit
WBC
Band
Segmenter
Basophil
Eosnophil
Lymphocyte
Monocyte
RBC
MCV
MCH
MCHC
MPV
RDW
Platelet Count
Reticulocyte
ESR
Creatinine Serum
Potassium
ALT
Sodium
14-17.5gm/dL
14-17.5
4.4-11.0
3%
56%
0.3%
2.7%
34%
4%
4.5-5.9 10 12/L
80-96fL
27.5-33.2pg
33.4-35.5%
--
--
150,000-450,000/cu
mm
0.5-1.5%
0.00-20.00mm/h
0.7-1.5mg/dL
3.6-5.0mmol/L
11-66uL
137-145mmol/L
6.77gm/dL
19.3
174,000
02%
05%
--
--
07%
61%
1.93 10 12/L
100fL
35.1 pg
35.0%
----
27,020/cu mm
----
2.1 mg/dL
3.0 mmol/L
59 uL
134 mmol/L
Decreased: AnemiaIncreased: Erythrocytosis
Increased: Infection
Decreased:
Decreased:
NORMAL
NORMAL
Decreased: Immuno –
deficiency
Increased: Viral
infections
Decreased: Anemia
Increased: Macrocytic
Anemia
Increased: : Macrocytic Anemia
NORMAL
NORMAL
NORMAL
Decreased: Acute Leukemia
NORMAL
NORMAL
Increased: Fever
Decreased: Diarrhea
NORMAL
Decreased: Metabolic
Acidosis
Uric Acid 2.5-7.5mg/L 11.9 mg/L Increased: Gout
Present Profile of the Functional Health Patterns
3.1 Health Perception Pattern
Before the patient was diagnosed with Acute Myelogenous Leukemia the patient
describes himself as a healthy individual. But as of now, he describes his condition as very poor due to
his present condition. In order for him to keep healthy, he must eat nutritious foods and must not over
fatigue himself. He follows the doctors order and take the medication as needed. The patient refuses to
have chemotherapy due to financial problems.
3.2 Nutritional Metabolic Pattern
Before the patient was not admitted in the hospital, he likes to eat any kind of foods.
But as of now, the patient does not want to eat and he vomits all the time. The patient drinks alcohol
mostly everyday, he prefers to drink Tanduay and Emperador. The patient also smokes and can consume
one pack per day. The patient takes vitamin supplements like Revicon and Everet. According to the
patient his weight had decreased from 180 pounds to 110 pounds.
3.3 Elimination Pattern
On the first week of his admission, the patient was having hematuria and melena. After
the following weeks, the patient’s foley bag catheter was already removed and the patient was
having no problems in urinating and defecating. The patient defecates once in a day.
3.4 Activity or Exercise Pattern
Before, the patient used to walk from his home to his office, but now even five steps he feels
fatigue and will have a difficulty in breathing. The patient was advised by the physician not to over
fatigue himself and he needs enough sleep and rest.
3.5 Cognitive or Perceptual Pattern
The patient cannot see from far objects. He wears eyeglasses so that he can see clearly. The
patient can hear well enough. The patient often times complains of fatigue and feels drowsy all the time.
The patient is able to read and write.
3.6 Sleep or rest Pattern
Before the patient’s hospitalization, he sleeps at 7: 00 pm to 6:00 in the morning, but
now because of his condition he sleeps most of the time. The patient has no problem in sleeping.
3.7 Self Perception Pattern
The patient is concerned about his illness. He is scared that he will die and might be far
away from his family. According to the patient, he wants to be free from Leukemia but it is too
impossible to happen, it needs some miracles. The patient describes himself as very religious especially
with his condition and he must need some faith to hold on to whatever circumstances might happen. His
condition made him different because unlike normal people he needs to wear a mask all the time.
3.8 Role Relationship Pattern
The patient prefers to speak Cebuano. He speaks clearly and fluently and he is able to
express himself freely. The patient lives with his family in Matab-ang Toledo City.
3.9 Coping or stress Tolerance Pattern
The patient and his wife both make the decision especially when it comes to health and
financial matters. He sometimes seeks help to his mother when it comes t o problem solving because he
is more comfortable in asking for assistance so that he can express his feelings. The patient is still
working but he will just go to work to punch in and leave.
3.10 Value or belief System
The patient is a Roman Catholic and God is very important to him. For him, God and his
family is his source of strength and meaning. The patient prays the rosary and attends mass every
Sunday. The patient wishes to go to Simala to pray for his condition. According to the patient, he just
accepts what Gods plan awaits him.
IV. Pathophysiology and Rationale
Anatomy and Physiology
The immune system defends the body from invading organisms that may cause disease.
One part of the immune system uses barriers to protect the body from foreign substances.
These barriers include the skin and the mucous membranes, which line all body cavities; and
protective chemicals, such as enzymes in saliva and tears that destroy bacteria. Another part of
the immune system uses lymphocytes, specialized white blood cells that respond to specific
types of foreign invaders. B lymphocytes produce proteins called antibodies, which circulate in
the blood and attack specific disease-causing organisms. T lymphocytes attack invading
organisms directly.
COMPONENTS OF THE IMMUNE SYSTEM
Macrophage Engulfing Bacterium
A macrophage, in yellow, engulfs and consumes a bacterium. Macrophages are large
phagocytes, cells that wander through the body consuming foreign particles such as dust, asbestos
particles, and bacteria. They help protect the body against infection.
White blood cells are the mainstay of the immune system. Some white blood cells, known as
macrophages, play a function in innate immunity by surrounding, ingesting, and destroying invading
bacteria and other foreign organisms in a process called phagocytosis (literally, “cell eating”), which is
part of the inflammatory reaction. Macrophages also play an important role in adaptive immunity in that
they attach to invading antigens and deliver them to be destroyed by other components of the adaptive
immune system.
LYMPHOCYTE
Lymphocytes are specialized white blood cells whose function is to identify and destroy invading
antigens. All lymphocytes begin as “stem cells” in the bone marrow, the soft tissue that fills most bone
cavities, but they mature in two different places. Some lymphocytes mature in the bone marrow and are
called B lymphocytes. B lymphocytes, or B cells, make antibodies, which circulate through the blood and
other body fluids, binding to antigens and helping to destroy them in humoral immune responses.
Other lymphocytes, called T lymphocytes, or T cells, mature in the thymus, a small glandular organ
located behind the breastbone. Some T lymphocytes, called cytotoxic (cell-poisoning) or killer T
lymphocytes, generate cell-mediated immune responses, directly destroying cells that have specific
antigens on their surface that are recognized by the killer T cells. Helper T lymphocytes, a second kind of
T lymphocyte, regulate the immune system by controlling the strength and quality of all immune
responses. Most contact between antigens and lymphocytes occurs in the lymphoid organs—the lymph
nodes, spleen, and tonsils, as well as specialized areas of the intestine and lungs (see Lymphatic System).
Mature lymphocytes constantly travel through the blood to the lymphoid organs and then back to the
blood again. This recirculation ensures that the body is continuously monitored for invading substances.
BONE MARROW
Bone Marrow, soft, pulpy tissue that fills the cavities of bones, occurring in two forms,
red and yellow. One of the largest tissues in the body, bone marrow accounts for 2 to 5 percent
of an adult’s weight. Red marrow, present in all bones at birth, serves as the blood manufacturing
center. As an infant matures, most of the red marrow in the shaft of long bones, such as the arm
and leg bones, is gradually replaced by yellow marrow. Yellow marrow is composed primarily of
specialized fat cells.
STRUCTURE
Red marrow consists primarily of a loose, soft network of blood vessels and protein
fibers interspersed with developing blood cells. The blood vessels are termed the vascular
component, and the protein fibers and developing blood cells collectively are referred to as the
stroma, or the extravascular component. The protein fibers crisscross the marrow, forming a
meshwork that supports the developing blood cells clustered in the spaces between the fibers.
Red marrow contains a rich blood supply. Arteries transport blood containing oxygen and
nutrients into the marrow, and veins remove blood containing carbon dioxide and other wastes.
The arteries and veins are connected by capillaries, blood vessels that branch throughout the
marrow. In various places, the capillaries balloon out, forming numerous thin, blood-filled
cavities. These cavities are called sinusoids, and they assist in blood-cell production.
Yellow marrow is so named because it is composed of yellow fat cells interspersed in a
rich mesh of connective tissue that also supports many blood vessels. While not usually actively
involved in blood formation, in an emergency yellow marrow is replaced by blood-forming red
marrow when the body needs more blood
MARROW FUNCTION
Red marrow produces all of the body’s blood cells—red blood cells, white blood cells,
and platelets. Red blood cells in the circulatory system transport oxygen to body tissues and
carbon dioxide away from tissues. White blood cells are critical for fighting bacteria and other
foreign invaders of the body .Platelets are essential for the formation of blood clots to heal
wounds. Within red bone marrow, all blood cells originate from a single type of cell, called a
hematopoietic stem cell. Stimulated by hormones and growth factors, these stem cells divide to
produce immature, or progenitor blood cells. Most of these progenitor cells remain in the stroma
and rapidly undergo a series of cell divisions, producing either red blood cells or white blood
cells. At any one time, the stroma consists largely of progenitor cells in various stages of
development. At the appropriate developmental stage, the fresh, new cells squeeze through the
walls of the capillaries. From there, the cells leave the bone and enter the body’s circulatory
system. Some progenitor cells migrate to the sinusoids, where they produce platelets, which also
travel to the circulatory system via the capillaries. Although stem cells are relatively rare—about
1 in every 10,000 marrow cells is a stem cell—they typically produce the forerunners of an
estimated 2 million red cells per second and 2 billion platelets per day. However, if significant
amounts of blood are lost or other conditions reduce the supply of oxygen to tissues, the kidneys
secrete the hormone erythropoietin. This hormone stimulates stem cells to produce more red
blood cells. To fight off infection, hormones collectively termed colony stimulating growth
factors are released by the immune system. These hormones stimulate the stem cells to produce
more infection-fighting white blood cells. And in severe cases, the body converts yellow marrow
into red marrow to help produce needed blood cells.
PREDISPOSING FACTORS
4.3 Discuss the disease process ands its effects on different organ/system
Leukemia Overview
CANCER
Canc er is a process of uncontrolled abnormal cell growth and development. Under
normal circumstances, cells are formed, mature, carry out their intended function, and then die.
New cells are constantly regenerated in the body to replace those cells and to maintain normal
cellular function. Cancer represents the disturbance of this process, which can occur in several
ways.Cells may grow and reproduce in a disorganized and out-of-control fashion. Cells may fail
to develop properly, so they will not function normally. Cells may fail to die normally. One or a
combination of these processes may occur when cells become cancerous.
LEUKEMIA
Leukemia is a cancer of blood-forming cells in the bone marrow. These deranged,
immature cells accumulate in the blood and within organs of the body. They are not able to carry
out the normal functions of blood cells.
Normal blood contains 3 major groups of cells: white blood cells, red blood cells, and platelets.
All 3 types of blood cells develop from one immature cell type, called blood/marrow stem cells,
in a process called hematopoiesis.
These stem cells divide and develop to a more developed, but still immature precursor, called a
blast, which then develops through several more stages, into a mature blood cell.
This process takes place in the bone marrow, which is the soft spongy material found in the
center of most bones.
Each type of blood cells has its own different and essential function in the body.
White blood cells (leukocytes) are part of the immune system and help fight a variety of
infections. They also help in the healing of wounds, cuts, and sores.
Red blood cells (erythrocytes) contain hemoglobin, which carries oxygen to, and removes
carbon dioxide from, the cells throughout the various organs of the body.
Platelets, along with certain plasma proteins, help plug the holes in blood vessels and form clots
once blood vessels are damaged or cut.
The first step in the process of stem cell maturation is differentiation into 2 groups: the myeloid stem
cell line and the lymphoid stem cell line.
The myeloid stem cells, or lineage, develop into red blood cells, platelets, and certain types of
white blood cells (granulocytes or monocytes).
The lymphoid stem cells, or lineage, develop into another type of white blood cell
(lymphocytes).
Either lineage can be affected by leukemia. Leukemias that affect the myeloid lineage are called
myelocytic (also myelogenous, myeloblastic, or nonlymphocytic) leukemias. Leukemias that
affect the lymphoid lineage are called lymphocytic (also lymphoblastic or lymphogenous)
leukemias.
Each of the 2 major types of leukemia, myelogenous and lymphocytic, include both acute and chronic
forms.
Acute essentially refers to a disorder of rapid onset. In the acute myelocytic leukemias, the
abnormal cells grow rapidly and do not mature. Most of these immature cells tend to die
rapidly. In the acute lymphocytic leukemias, growth is not as rapid as that of the myelocytic
cells. Rather, the cells tend to accumulate. Common to both types of leukemia is their inability
to carry out the functions of healthy white blood cells. Untreated, death occurs within weeks or
a few months.
In the chronic leukemias, the onset tends to be slow, and the cells generally mature abnormally
and often accumulate in various organs, often over long intervals. Their ability to fight infections
and assist in repairing injured tissues is impaired. However, unlike the acute forms of leukemia,
untreated, these disorders may persist for many months or, as in the chronic lymphocytic group,
many years. A distinctive feature of the chronic myelocytic type is its invariable conversion, if
untreated, to a more rapidly fulminating acute type, leading to rapid death.
WHAT HAPPENS IN LEUKEMIA?
When a large number of blasts (leukemic cells) appear in the bone marrow, several
things happen. As the leukemic blast cells accumulate in the bone marrow, they begin to crowd
out the normal blood cells that develop there. Eventually, they take up so much room that red
blood cells, platelets, and normal white blood cells cannot be produced. When that happens,
the young person develops symptoms indicating that normal blood cells are not being
manufactured in adequate numbers:
If red blood cells are crowded out by leukemic cells, the blood will look thin, which makes the
patient look pale. The young person also may be tired, because the thin blood cannot carry
enough oxygen to the heart, lungs, and muscles.
If blood platelets are crowded out in the bone marrow, the young person may have bleeding
problems and unusual bruising.
If the normal, mature kind of white cells known as neutrophils are crowded out by the blasts,
there will be no cells to combat bacteria, and infections may occur.
In some cases, leukemic blasts may spill over from the bone marrow into the blood, where they
can be seen by microscopic examination. This may cause a rise in the number of white cells in
the blood (the white blood cell count). In other cases, only a few blasts appear in the blood, and
the white cell count does not change much. When leukemic blasts are present in the blood, they
may be carried to other places in the body and enter various body organs. Sometimes they grow
in these organs as well as in the bone marrow.
Cancer cells Normal cells
ACUTE MYELOGENOUS LEUKEMIA
A PICTURE OF ACUTE MYELOGENOUS LEUKEMIA
Acute myelogenous leukemia (AML) is a cancer of the blood and bone marrow — the spongy
tissue inside bones where blood cells are made.
It's called acute leukemia because it progresses rapidly and affects immature blood cells,
rather than mature ones. It's called myelogenous (MI-uh-loj-uh-nus) leukemia because it affects a
group of white blood cells called the myeloid cells, which normally develop into the various
types of mature blood cells, such as red blood cells, white blood cells and platelets. This type of
leukemia is also known as acute myeloid leukemia, acute myeloblastic leukemia, acute
granulocytic leukemia and acute nonlymphocytic leukemia.
Normally, your bone marrow produces immature cells (stem cells) in a controlled way, and they
mature and specialize into the various types of blood cells as needed. In people with acute
myelogenous leukemia, the bone marrow produces immature cells that usually develop into a
type of abnormal white blood cell. These abnormal cells aren't able to mature and perform their
usual functions. Even worse, they multiply rapidly and can crowd out healthy cells, leaving a
person with acute myelogenous leukemia vulnerable to infection, anemia or easy bleeding.
Leukemia cells can also spread outside the blood to other parts of your body.Acute myelogenous
leukemia is the most common form of leukemia. It worsens quickly if not treated, but it initially
responds well to treatment. Unfortunately, many people with acute myelogenous leukemia
experience a relapse. Much research is focused on decreasing the risk of relapse and improving
the long-term outcomes for people with acute myelogenous leukemia
CAUSES
The cause of acute myelogenous leukemia is damage to the DNA of developing cells in
your bone marrow. Under normal circumstances, your DNA is like a set of instructions for your
cells, telling them how and when to grow and divide. Certain genes on your DNA called
oncogenes promote cell division. Other genes, called tumor suppressor genes, slow down cell
division and cause cells to die at the appropriate times.
Acute myelogenous leukemia can occur when damage to DNA turns on oncogenes or turns off
tumor suppressor genes. When this happens, blood cell production goes awry. The bone marrow
produces immature cells that develop into leukemic white blood cells called myeloblasts. These
abnormal cells are unable to function properly, and they can build up and crowd out healthy
cells.The DNA mutations that cause leukemia are usually acquired — rather than inherited —
but researchers and doctors don't always understand exactly how. In some cases, damage to DNA
is the result of exposure to cancer-causing chemicals, including previous chemotherapy for other
cancers. There's also a chance of AML progressing from other blood diseases and chronic
leukemias, such as chronic myelogenous leukemia, myelodysplasia or other disorders in which
the bone marrow produces too much of certain types of blood cells (myeloproliferative
disorders).
RISK FACTORS
The risk of acute myelogenous leukemia increases with age. It's most prevalent in people in
their 60s and older. The disorder is also more common in males than in females. Other possible
risk factors include:
Cancer therapy. People who've had certain types of chemotherapy and radiation therapy or
treatment for childhood acute lymphocytic leukemia (ALL) may have a greater risk of developing
AML.
Exposure to radiation and certain chemicals. People exposed to very high levels of radiation,
such as survivors of an atomic bomb blast or a nuclear reactor accident, have an increased risk
of developing AML. Exposure to certain chemicals, such as benzene — which is found in
unleaded gasoline and used by the chemical industry — also is linked to greater risk of AML.
Smoking. AML is linked to cigarette smoke, which contains benzene and other known cancer-
causing chemicals. Smokers older than 60 face twice the risk of AML that nonsmokers do.
Other blood disorders. People who've had another blood disorder, such as myelodysplasia,
polycythemia vera or thrombocythemia, are at greater risk of developing AML.
Genetic disorders. Certain genetic disorders, such as Down syndrome, are associated with an
increased risk of AML.
CLASSICAL SYMPTOMS CLINICAL SYMPTOMS RATIONALE
Anemia
Dyspnea
Fatigue
Pale skin, mucous
membrane,
conjunctiva, nail beds
Manifested
During the assessment, the
student nurse observed that
the patient has a pale skin,
oral mucosa, conjunctiva and
nail beds. The patient also
verbalizes that he feels weak
and sometimes he had
difficulty in breathing even
doing things with no exerted
force.
More specific signs and
symptoms of acute
myelogenous leukemia are
caused by a lack of properly
functioning blood cells,
resulting from overcrowding
by leukemia cells. The oxygen
carrying capacity of
hemoglobin is reduced
causing tissue hypoxia and
can result to fatigue,
weakness and dyspnea
(p. 276 disease management
for nurse practitioner by:
Thrombocytopenia
Bleeding
Manifested
The patient had a low platelet
count levels (27,020cu mm)
Manifested
One week prior to admission,
the patient experiences
hematuria and bloody stools.
The patient also has petechiae
in his surrounding skins.
Scilling)
In acute melogenous
leukemia, there is the loss of
bone marrow function
because of the replacement of
the malignant cells such as
occurs in leukemia, which
results in decrease production
of platelets
(p. 265 disease management
for nurse practitioner by:
Scilling)
In acute myelogenous
leukemia, bleeding is evident
because of a decrease
circulating platelets or
impaired platelet function.
Bleeding that results from
platelet deficiency commonly
occurs in small vessels and is
characterized by petechae
and purpura
(p. 265 disease management
Neutropenia
infection
Manifested
The patient was advised by his
physician to wear mask all the
time and must eat foods that
ca boost his immune system
for nurse practitioner by:
Scilling)
In acute myelogenous
leukemia, the bone marrow
produces immature cells that
usually develop into a type of
abnormal white blood cell.
These abnormal cells aren't
able to mature and perform
their usual functions. Even
worse, they multiply rapidly
and can crowd out healthy
cells, leaving a person with
acute myelogenous leukemia
vulnerable to infection
(http://www.mayoclinic.com)
The symptoms of AML are
caused by low numbers of
healthy blood cells and high
numbers of leukemia cells.
White blood cells fight
infection. Low numbers can
fever
Manifested
The patient had fever one
week prior to his admission
because of massive tonsillitis
lead to fever and frequent
infections. With
immunosuppression the body
the body is often unable to
respond an infection with a
characteristic indicator, such
as fever
(http://www.marrow.org)
(p. 660 Nursing Care of
acutely ill and chronically ill
patient by: Lagerquist)
In patient who is immune-
suppressed, the oral mucous
membranes are often a
source of infection; therefore
a complain of a sore throat is
an important of early
indication of a potential
problem
(p. 660 Davis’s NCLEX- RN
tonsillitis
Manifested
The patient complains of
having difficulty in swallowing
because of tonsillitis.
Not Manifested
Not Manifested
Not Manifested
Success by: Lagerquist)
These is because of the
proliferation of leukemia cells
within organs
(p. 897 medical- surgical
nursing by: Brunner)
Spleenomegaly
Hyperplasia of the gums
Bone pain
Nursing Interventions
1. Care Guide in Patient with disease Condition
TREATMENT
Treatment of patients with acute myelogenous leukemia depends on age and the subtype of
the disease. In general, treatment falls into two phases:
Remission induction therapy. The purpose of the first phase of treatment is to kill the leukemia
cells in your blood and bone marrow. However, remission induction usually doesn't wipe out all
of the leukemia cells, so you need further treatment to prevent the disease from returning.
Consolidation therapy. Also called post-remission therapy, maintenance therapy or
intensification, this phase of treatment is aimed at destroying the remaining leukemia cells. It's
considered crucial to decreasing the risk of relapse.
Therapies used in these phases include:
Chemotherapy. Chemotherapy is the major form of remission induction therapy. A
common course of therapy involves two chemotherapy drugs — cytarabine (Cytosar-U),
followed by an anthracycline drug, such as daunorubicin (Cerubidine) or idarubicin
(Idamycin). A third medication, thioguanine, is sometimes used.
If you have AML, you'll probably stay in the hospital during the treatment cycle because
the chemotherapy destroys many normal blood cells in the process of killing leukemia
cells. This chemotherapy can cause anemia, infection and bleeding. If the first cycle of
treatment doesn't cause remission, you may need it repeated one or two more times. Other
drug combinations also may be used, depending on your specific situation.
Chemotherapy can also be used for consolidation therapy. This phase may include a
combination of different medications that mimic the induction, but usually includes high
doses of cytarabine by itself for one to three cycles. Your doctor may also prescribe
medications that boost white cell production to reduce the risk of infection. These
medications are called granulocyte colony stimulating factors (Neupogen, Leukine).
Other drug therapy. Arsenic trioxide and all-trans retinoic acid (ATRA) are anti-cancer drugs that
can be used alone — or in combination with chemotherapy — for remission induction of a
certain subtype of AML called promyelocytic leukemia. These drugs cause leukemia cells with a
specific gene mutation to mature and die, or to stop dividing.
Biological therapy. Also known as immunotherapy, biological therapy uses substances that
bolster your immune system's response to cancer. Monoclonal antibodies are one form of
biological therapy. These antibodies are produced in a laboratory, but they mimic protein
products found in your immune system (antibodies) that attack foreign substances (antigens) on
leukemic cells. Gemtuzumab ozogamicin (Mylotarg) is a monoclonal antibody linked to a
chemical toxin that attaches to AML cells. It's used to treat older people with AML who don't
respond to initial treatment or who relapse after successful initial treatment. Researchers are
testing its effectiveness in younger people with AML.
Bone marrow transplant. This is another option for consolidation therapy for people at high risk
of relapse or for treating relapse when it occurs. This procedure allows someone with leukemia
to re-establish healthy stem cells by replacing their leukemic bone marrow with leukemia-free
marrow. If you choose this treatment, you'll receive very high doses of chemotherapy or
radiation therapy to destroy your leukemia-producing bone marrow. This marrow is then
replaced by bone marrow from a compatible donor (allogeneic transplant). In some cases, you
may also be able to use your own bone marrow for transplant (autologous transplant). This is
possible if you go into remission and then save healthy bone marrow for a future transplant.
Stem cell transplant. Stem cell transplant is also used for consolidation therapy. It's similar to
bone marrow transplant except the stem cells are collected from circulating blood (peripheral
blood), rather than from the bone marrow, thanks to a medication that causes larger numbers
of stem cells to be released from the bone marrow. The cells used for transplant can be your
own healthy cells, or they can be collected from a compatible donor. This procedure is used
more frequently than bone marrow transplant because of shortened recovery times and
possible decreased risk of leukemia recurrence.
Radiation Therapy.Radiation therapy involves the use of radiation to kill cancer cells
and shrink tumors. For AML, external radiation therapy is used.In external radiation
therapy radiation is directed at the tumor from a source outside the body. This type of
treatment is used for AML that has spread—or may spread—to the brain and spinal cord.
It can also be used to treat bone pain that comes from bone affected by the leukemia.
NCP
s- “ dali na kayo ko kutasan ug kapuyan na ko dae, mga lima ka lakang kapuyon na ko” as verbalized by
the patient
o- weakness
-feeling of exhaustion
-low RBC counts: 1.93
- low hemoglobin count: 6.77
-shortness of breath
-fatigue
-blood pressure: 100/60 mmhg
A- Activity Intolerance: fatigue related to anemia
P- demonstrate a decrease in physiologic signs of intolerance
I- plan care with rest periods between activities
elevate head of bed as tolerated
provide positive atmosphere, while acknowledging difficulty of the situation of the patient
provide quiet environment, maintain bed rest as indicated. Limit visitors, phone calls and reported unplanned interruptions
prioritize nursing care schedules to enhance rest.
use energy techniques such as shower chair, sitting performing task
provide assistance with patient, including activities that the patient views as essential. Increase activity levels as tolerated
instruct patient to stop activity if palpitations, chest pains, shortness of breath, weakness, dizziness occur
change patient position slowly and monitor for dizziness
E- the patient shows a decrease signs of intolerance
s- “ ingon si doc dae na pa mason ko niya kai para dili ko ma takdan sa mga sakit”
As verbalized by the patient
o- increase white blood cells:174,000
presence of immature leukocytes
compromised immunity
wears mask
low eosinophil: 0%
low lymphocyte: 07%
A- Risk for infection related to proliferation of immature lymphocytes
P- the client will be free from acquiring infection
I- maintain a fluid intake of at least 2500 ml per day
use good handwashing technique and encourage patient to do the same
protect client from others with infections
instruct and assist client to perform good oral hygiene as often as needed
instruct patient to wear mask all the time
eliminate fresh salads and unpeeled fresh fruits and vegetables
allow no fresh flowers
administer antimicrobials as needed
E- the patient shows a decrease signs of intolerance
s- “ pait kaau ning akong kahimtang, naa pa koi mga anak nga gagmay sa tanan ako pa jd wala mn me
kwarta” As verbalized by the patient
o- sad facial expression
crying
A- Anticipatory grieving related to possible loss of loved one
P- will be able to express feelings of anxiety
I- encourage verbalization of fears, concerns and questions regarding disease treatment
encourage active participation of patient or family in care and treatment decisions
be with patient most of the times
encourage verbalization of negative feelings, including anger and hostility
allow periods of crying and expression of sadness
use therapeutic communication skills of active listening, silence, acknowledgement
advise for professional counseling
permit verbalization of anger with acknowledgement of feelings and setting of limits regarding destructing behavior
E- the patient was able to verbalize feelings of anxiety
OBJECTIVES CONTENTS METHODOLOGY
EVALUA-TION
GOAL: After 3 days of varied teaching and learning experience, the patient and significant others will be able to gain knowledge, attitude and skills about his disease condition and how to prevent fatigue.
After 45 minutes of student nurse-patient interaction, the patient will be able to:
1. identify predisposing factors in acquiring leukemia
2. enumerate signs and symptoms of leukemia
1. predisposing factors in acquiring leukemia1.1 expose to radiation for a
long period1.2 genetic factors such as
down syndrome1.3 exposure to chemicals
such as benzene and drugs that causes aplasic anemia
2. signs and symptoms of leukemia2.1 fever and infection
related to decrease in white blood cells
Informal discussion
Informal discussion
3. determine the significance on wearing a mask all the time
4. the patient will show interest during the health teaching
5. demonstrate beginning skills on preventing fatigue by clustering scheduled activities
2.2 weakness and fatigue from anemia
2.3 bleeding tendencies from decreased platelets
3. significance on wearing mask all the time3.1 this is to prevent the
patient from acquiring any infection
4. shows interest during the health teaching4.1 asks questions during the
interaction of the student nurse
4.2 participates and encourages the student nurse to go on to the discussion
4.3 Shows interest on the discussion by cooperating with the student nurse
5. clustering scheduled activities5.1 teach client on how to
cluster activities to prevent fatigue example:Monday: 7:00-7:30 (eating breakfast)7:30 – 9:00 watching television for relaxation9:00-9:30 perform exercise such as walking9:30-10:00 reading books …
5.2 let the patient decide and schedule his planned activities
Informal discussion
Informal discussion and utilization of pictures
Scheduling activities and Informal discussion
VII. Evaluation and Recommendation:
Early detection of an ailment is vital to the patient. Oftentimes lack of in-depth
knowledge regarding a condition of a disease may hinder a patient in seeking immediate advice
from medical specialist. Fear and financial problems may sometimes interfere which may often
lead to the severity of the disease.
This I believe is one of the major causes as to why my patient has gone to this terminal
stage of his Acute Myelogenous Leukemia (AML). The nature of his job as a painter exposes
him to great risk of an organ damage. Petroleum products when exposed to a person to a
considerable period of time may often lead a person to this problem. This is also coupled with
lack of knowledge regarding this health hazard.
According to his recent laboratory results, his platelet is 27,000 /cu mm which is very
low compared to the normal platelet count of 150,000-450,000/ cu mm. This shows a decrease in
both platelets and erythrocytes. The patient shows hematuria, melena and petechiae on his both
upper and lower extremities, this is an indication of decrease in platelet as well. Because of lack
of mature and normal granulocytes, the patient had a massive tonsillitis. Since treatment for
chemotherapy is too costly for the patient this could contribute for a compelling severity of his
health condition.
It is necessary to undertake sessions of chemotherapy to prolong the patient’s life.
Immaturity of leukocytes can also lead to severe infection, the patient is encouraged to wear
mask whenever the condition necessitates. The patient needs proper rest due to fatigue. He also
needs more encouragement from his immediate family member, relatives and friends.
Government sector plays a great role in sustaining financial support for indigent patients.
Health care institutions can also help in the financial assistance of their members. Advancement
of medical technology and profession is always a mileage in the science of medical world.
DTR
VII. Bibliography
Porth, Carolwatson.” Pathophysiology”.6th edition.
Schilling, Judith A. RN, MSN “ Disease management for Nurse Practitioners”.
Smeltzer, Suzanne. Bare, Brenda. “Medical-Surgical Nursing. 10th edition. Lippincott Wiliams and Wilkins.
Lagerquist, Sally. “ Nclex-RN Success” F.A. Davis Company
Marieb, Elaine. “Essentials of Human Anatomy and physiology” 7 th edition.Pearon
education Inc., San Francisco, California. 2003.
Smeltzer. Bare. “ Medical-Surgical Nursing”. 10th edition.
Patrick. “ Medical-Surgical Nursing”. 2nd edition.
Phipps. Long. Woods. “Medical-Surgical Nursing”
INTERNET:
http://healthgate.partners.org
www.mayoclinic.com
www.cancerlinkusa.com
www.niaid.nih.gov]
Microsoft encarta 2006 PremiuM